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Nurses Week 2016: CNOs Speak Out On Safety

Innovations and Advice for Better Practice

Since the theme of National Nurses Week 2016 is “Culture of Safety: It Starts with You,” we decided to make safety the focus of our annual roundtable. Throughout the issue, nursing leaders from local hospitals share their thoughts on what institutions and individual RNs can do to make hospitals safer.

Q: Is there a recent or upcoming safety-related change or innovation at your hospital that you’re particularly excited about or proud of ?

Alarm Fatigue

We have worked very hard to decrease alarm fatigue. Our staff is very good at setting alarm limits specific to the patients, which means there’s no excessive noise caused by non-actionable alarms. That results in a less-stressful environment for the staff and a safer healing environment.

Approximately one year ago, a team of clinical stakeholders participated in a week-long kaizen [continuous improvement] event to redesign patient throughput in the emergency department. Door-to-provider times went from an average of 114 minutes to 21 minutes for high-acuity patients and 51 minutes for patients receiving treatment and discharge.

We are in the midst of completing safe patient handling training for all patient care staff, regardless of department. The training includes the use of the many pieces of new equipment we have purchased to support safe movement of patients. The sessions have been well-received and have helped us prioritize which additional equipment is most desired by staff.

We have implemented a new process in our ED called “Team Care,” which is designed to facilitate quickly moving patients to the appropriate provider based on acuity. This also ensures those very sick patients are not held up in our waiting area while waiting for beds.

Our “MOVIN’ @ RCH” program — which was proposed and led by one of our nurses based on research she did as part of her BSN program — emphasizes early mobility to combat deconditioning, prevent hospital-acquired conditions and improve patient experience.

As a brand-new hospital, we are very innovative here at MLKCH. For example, our EHR is smoothly integrated with 30-plus devices, including smart pumps that that replenish IV bags and smart beds that weigh patients and provide safety alarms if a patient falls from their bed.

A “must have” for every hospital and healthcare institution is barcode verification technology for the electronic medication administration system. When nurses are diligent about scanning each medication before administration, medication errors are virtually eliminated.

I am hopeful that technology will soon allow us to electronically track hand hygiene adherence. We know that good hand hygiene is important for reduction of many infections. Having better tools to monitor adherence will aid us in ensuring 100 percent compliance.

I would like all organizations, including nursing schools, to adopt TeamSTEPPS methodology to improve communication in patient care. Having “trigger words” which have the same meaning to all healthcare providers is a powerful tool for ensuring patient safety.

I always want the patients involved in their reporting. At shift changes, we want to ensure that our reporting includes where the patient is not only clinically, but also emotionally. That way, nurses are able to engage and interact with patients in a much more productive manner.

Q: A major safety issue for nurses, particularly ED nurses and those on psychiatric units, is workplace violence. What are some specific steps your institution is taking to better protect nurses?

Safety Workshop

Last year, we brought the security officers and the ED staff together for a workshop to address safety and better communication for the team, especially during high-stress times when census is high and wait times are prolonged. Numerous interventions came out of this project. As a result, the ED nurses feel safer in their environment.

Some of the steps our organization has employed include providing four hours of mandatory training on how to effectively manage aggressive and assaultive behaviors; screening every patient at intake to assess potential risk to themselves or others; placing a security officer in the ED; and an ED renovation and expansion that added stripped-down safe rooms, a tempered glass enclosure for the nursing station and several panic buttons.

Our security team is amazing and has collaborated in the development of content that we use with staff for our Code Grey and Code Grey Adam events as well as a video focused on an active shooter situation. Our staff have identified this content as being extremely beneficial to them.

One of the enhancements we have initiated is a dedicated psychiatric “sitter” program in which all ED “sitters” are required to be in-serviced by our behavioral health team prior to working with psychiatric patients. Also, if we are “boarding” psychiatric patients in the ED, a behavioral health nurse from our inpatient unit will round on the patient at least once per shift.

Q: Electronic health recordkeeping is now a reality in most institutions. Has the adoption of EHRs and electronic charting been a boon to patient safety, an obstacle or both?

Eliminating Human Errors

There are days when it is both. The beauty of the electronic record is that it is organized and easily read. Also, it is now possible to interface the EHR with technology like the infusion pump, which eliminates some of the human errors that occurred with manual systems.

One benefit of the EHR has been the ability to incorporate hard stops into the documentation process that require clinicians to enter essential clinical information. On the other hand, documenting in the EHR can be time-consuming and fragmented. Nurses spend too much time in front of a computer screen, taking away valuable one-on-one time with patients.

There have been some improvements, such as being able to include key elements in standard orders and/or force documentation of key areas of observation. But, no system is perfect. It’s important to ensure that challenging documentation issues and staff “workarounds” are identified and resolved to ensure that unsafe practices do not develop or perpetuate.

The EHR has supported many patient safety initiatives, most notably in medication administration. However, with any new initiative, process flow is essential. Our informatics team has worked hard to ensure that the documentation modules support the workflow of the nurses at bedside.

Having the patient’s records available across the continuum of care is a significant patient safety advance. However, with the advent of EHR systems, we as nurses have slowly gravitated to “task-oriented” patient care, relying on work lists to tell us when to check on the patient.

Once we got over the initial learning curve, the EHR has not become the obstacle many have warned. The clinical staff spend no more time documenting than they did in the past. Documents are legible, immediately accessible and much more complete than before.

Q: Safety concerns are a big obstacle for new nurses in getting their first nursing jobs. What is your hospital’s policy/attitude towards hiring new nurses and helping them develop their ability to practice safely?

Versant Program

We developed a Versant nurse residency program at CHLA to bridge the transition from school to the workforce. There are confidential debriefing sessions, a preceptor program and a mentor program to support the new graduate as they learn the safety essentials. I encourage all new nurses to go to a hospital with a residency program that provides this support.

We are one of the few hospitals in the San Gabriel Valley to offer a new graduate nurse residency program. Our entry level of new staff hiring is at the BSN level. Depending on the area of practice, the residency program spans 12 to 16 weeks. All new graduates are partnered with a preceptor.

We have developed new grad orientations for most of our nursing areas. New nurses can be developed into very strong members of your nursing workforce if you are willing to invest some extra time with them and often bring a renewed “fire” to your organization.

Our hospital will soon start having new grad programs again, which I am excited about. Nursing departments thrive when new staff come into the mix. It stimulates questions and experienced nurses get to teach.

We have a robust new graduate internship program designed to provide a supportive environment encouraging the new grad to assimilate into the professional nursing workforce. We allow the graduate nurse to choose their area of specialty. Depending on the area, the program could last between four months and one year.

Right now, we do not recruit new grads because as a start-up hospital, we operate in a fluid atmosphere, which can make for a difficult environment for new grads. In the future, we would like to bring in graduates with the right attitude and the non-teachable skills we expect.

Q: If you could give all RNs one suggestion or piece of advice about how they can improve safety in their institutions, what would it be?

Ask Questions

Ask questions if you don’t know why a specific medication or therapy is being given or if something doesn’t sound or look right. No question is a stupid question — nurses need to understand why they are doing what they are doing. It keeps patients safe.

Communicate with your patients. Patients want to be heard and know their concerns are being addressed. We may not always be able to facilitate their desires, but we at least need to hear their concerns.

Every day when you go home, read about the conditions of the patients you cared for that day, review medications and learn as much as you can. Also, never forget that you are caring for a person. If you always remember that you are caring for another human being, you’re more likely to avoid shortcuts and pay attention to all aspects of care.

Keep learning and growing. When I graduated, my nursing instructor told me, “You are now just beginning. We have not taught you everything you need to know. We have only given you the tools to find what you need to know.”

Be ready for the times you will ask yourself, “What is the best decision I can make for this patient?” If you can make that best, safest decision, you’re not going to be far off. And if it doesn’t feel right, say something and keep saying it until someone listens to you.